integumentary practice

60 terms by tori_love5 

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The day following surgery, the nurse notes bloody drainage on the dressing. The nurse will record this drainage as

sanguineous

The nurse explains that the advantage of the occlusive dressing is that it

keeps the incision moist

When the nurse discovers that the gauze dressing has adhered to the wound, the nurse should

Moisten the dressing with sterile water

Because the physician has not ordered a dressing change for a draining wound, the nurse should assess the amount of drainage by

Circling and dating the outline of the exudates on the dressing

When the nurse assesses that blood and fluid flow into the vascular space and produce edema, erythema, heat, and pain, the nurse is aware that the phase of healing is

Inflammatory

In an attempt to keep the patient comfortable during a dressing change, the nurse may administer an analgesic

30 minutes before the change

When there is sustained skin pressure, especially over bony prominences, pressure ulcers may form due to

Collapse of the blood vessels

To meet the needs of an unconscious patient with a risk for skin impairment, the nurse will plan to have the patient's position changed every

120 minutes

The nurses assesses a red blister over the right superior iliac area and documents this decubitus as a

Stage 2

The nursing assessment of a pressure ulcer includes size and depth, pain, odor, and color of tissue in order to evaluate

Whether improvement is occurring

The nurse is attempting to avoid a pressure ulcer for her bedrest patient by turning him every 2 hours and moving him to which favorable position?

30 degree lateral

When providing hand and foot care, the person best prepared to provide nail care for patients with extremely hard nails is the

Podiatrist

When the nurse discovers a reddened area over the hip, the first assessment should be to

Press the area gently to assess for blanching

When the nurse is collecting a specimen for a wound culture, the specimen should never be collected from

Old drainage

A patient has generalized macular-papular skin eruptions and complains of severe pruritus. When the nurse administers his therapeutic bath, it is important to remember that

Using burrow solution helps promote healing

A patient, age 63, has cancer of the left breast. After a modified radical mastectomy, she has been receiving chemotherapy. Her grandson, who visited a few days ago, now has varicella (chickenpox). The nurse should observe her carefully for signs of

Herpes zoster

A patient has herpes zoster (shingles). A local antiinfective agent, which is useful in delaying the progression of herpetic diseases, was prescribed. This medication is

Acyclovir (zovizax)

A patient has been sent home from work with pruritus and honey-colored crusts on his lower lip and chin. A probable diagnosis would be

Impetigo

A patient has an erythematous patch of vesicles on her scalp, and she complains of pain and pruritus. A diagnosis of tinea capitis is made. The causative organism is

Fungus

A patient, age 46, reports to his physician's office with urticaria and papules on his hands and arms. He says, "It itches so badly." In assessing the patient, the nurse should gather data regarding recent

Changes in meds

A patient has been receiving penicillin, acetaminophen with codeine, and hydrochlorothiazide for 4 days. He now has a urinary tract infection. A sulfonamide has been prescribed to be taken three times per day. Several hours later, he complains of pruritus. The nurse observes a generalized erythema and rash. The most appropriate nursing intervention would be to hold

All meds, and notify the physician of the signs and symptoms

A patient has acne vulgaris. When the nurse explains this condition, it is most important to

Explore how this condition is affecting his self image

A 30-year-old African American had surgery 6 months ago. Her incisional site is now raised, indurated, and shiny. This tissue growth is most likely a(n)

Keloid

A patient, age 37, sustained partial- and full-thickness burns to 26% of her body surface area. The greatest fluid loss resulting from her burns will usually occur

Within 12 hours after burn trauma

Most of the deaths from burn trauma in the emergent phase that require a referral to a burn center result from

Infection...

A patient, age 26, is admitted to the burn unit with partial- and full-thickness burns to 20% of his body surface area as well as smoke-inhalation injury. Carbon monoxide intoxication secondary to smoke inhalation is often fatal because carbon monoxide

binds with hemoglobin in place of oxygen...

A nurse arrives at an accident scene where the victim has just received an electrical burn. The nurse's primary concern is

The likelihood of cardiac arrest...

A patient, age 27, sustained thermal burns to 18% of her body surface area. For the next 72 hours, the nurse will have to observe for the most common cause of burn-related deaths, which is

Infection

A duodenal ulcer may occur 8-14 days after severe burns. Usually, the first symptom is bright red emesis. Which condition matches this description?

Curling's ulcer...

A nurse is providing the occlusive method of treatment for a patient who is 52 years old with burns to her lower extremities. It would be important for the nurse to

Keep the room temperature at 85 F (24.4 C)

The nurse has initiated measures to promote suppuration of a carbuncle. Which of the following would indicate that these measures have been successful?

The area has begun to drain exudates...

A patient, age 20, is admitted with severe eczema. In planning the care for her, the nurse should plan to

Keep the skin well hydrated...

The nurse is caring for a 26-year-old patient who was burned 72 hours ago. He has partial-thickness burns to 24% of his body surface area. He begins to excrete large amounts of urine. The nurse should

Assess for signs of fluid overload

A patient, age 29, is diagnosed with genital herpes. She is receiving acyclovir (Zovirax). Which of the following would indicate a therapeutic response?

Decrease in pain

A female patient is seen by the school nurse because of flat lesions that are clear in the center with erythematous borders. In assessing a patient for tinea corporis, the nurse would check

Anterior abdomen

A patient has been walking in the woods. He complains of severe pruritus. The nurse notes an erythematous area on his lower legs. The first nursing intervention for dermatitis venenata would be to

Wash area with copious amounts of water

The nurse is débriding a wound. It is important to débride the wound to

Prevent infection and promote healing

A patient has been admitted to the hospital with burns to his upper chest. The nurse notes singed nasal hairs. It would be important for the nurse to assess this patient frequently for

Respiratory complications

Which of the following may indicate a malignant melanoma in a nevus on a patient's arm?

Irregular border of the mole

A dark-skinned patient has been admitted to the hospital in severe respiratory distress. To determine whether the patient is cyanotic, the nurse uses what knowledge of skin assessment?

Cyanosis can be seen in the lips and mucous membranes of patients with dark skin

A patient developed a severe contact dermatitis of her hands, arms, and lower legs after spending an afternoon picking strawberries. She states that the itching is severe and she cannot keep from scratching. Which instruction by the nurse will be most helpful in managing the pruritus?

Use cool, wet dressings and baths to promote vasoconstriction

A patient is a 32-year-old woman whose mother recently died from malignant melanoma. She asks the nurse about what she can do to prevent the development of malignant melanoma in herself and her children. The best response by the nurse includes which information regarding risk factors for melanoma?

Avoid exposure to the sun and use protective measures when exposure occurs

If the blood vessels of the skin dilate, the person appears

Flushed

Ceruminous glands

Secrete wax in the outer ear

Freckles and moles are caused by an accumulation of

Melanin

Which of the following is a consequence of a congenital absence of eccrine glands?

Inability to regulate body temperature

Radiation, conduction, convection, and evaporation are terms that are concerned with

Heat loss

Hives are called

Urticaria

What is the color of skin that is supplied by oxygen-poor blood?

Cyanotic

Which of the following substances makes the skin water-resistant?

Keratin

What is the result of the contraction of the arrector pili muscles?

Goosebumps

Which gland is most likely to develop a blackhead or pimple?

Sebaceous

Which of the following has the poorest prognosis?

Melanoma

Anticancer drugs often cause hair loss, a condition called

Alopecia

What is the name of the thickening of the epidermis that develops in response to constant pressure or irritation?

Callus

Melanocytes

Secrete a tanning pigment in response to exposure to sunlight

Cyanosis

Refers to a bluish coloring of the skin caused by hyoxemia

Apocrine glands

All of the above are true

To lose heat, flushing is generally accompanied by

Activation of the eccrine glands

Shivering

Produces heat

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